The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

DIVINE SAVIOR HEALTHCARE 2817 NEW PINERY ROAD PORTAGE, WI 53901 April 23, 2013
VIOLATION: LIST OF HOME HEALTH AGENCIES Tag No: A0823
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on MR review, review of facility discharge information for Pts, and interview with staff, in 6 of 9 MRs (1, 2, 4, 5, 7, and 9) the facility failed to ensure Pts are provided with a list of HHA, SNFs and CBRFs, informed of their freedom of choice for post care agencies and that the list discloses any agency with financial interest or affiliation with the hospital. This deficiency potentially affects all 32 In-Pts and Out-Pts seen in the facility on 4/23/13.


Findings include:

Per review of the facility's lists of SNFs (n.d.) and CBRFs (n.d.), available in the community for post hospital care, there is no indication on the lists that Tivoli SNF and CBRF are affiliated or are financially contected to DSH.

Per interview with SWS E on 4/23/13 at 1:40 PM, SWS E stated the staff do not give the lists of SNFs, HHAs, or CBRFS to all Pts requiring post hospital care, unless they did not have a preselected facility or agency. SWS E stated in interview, the SNF and CBRF lists do not indicate which facilities that have a financial interest or affiliation with DSH, Tivoli SNF and CBRF.

Pt #1's MR review on 4/23/13 at 10:55 AM, revealed Pt #1 was admitted on [DATE], after a fall, for hip surgery. The DC planning revealed Pt #1 would need SNF services for rehabilitation. There is no documentation in the MR that Pt #1 was given a list of SNFs to chose from, informed of the freedom of choice and disclosure of the financial interest or affiliation Tivoli has with DSH. This is confirmed in interview with SWS E on 4/23/13 at 1:40 PM.

Pt #2's MR review on 4/23/12 at 11:15 AM, revealed Pt #2 was admitted to SB from a Madison hospital on [DATE] pending an available bed in Tivoli SNF. There was no documentation in the MR of which SNF was chosen by the Pt. DC notes on 3/14/13 at 11:18 PM state "(Pt #2) was to go to Tivoli on Monday (3/13) but they are quarantined due to the flu." Pt #2 was kept in SB status until transfer to Tivoli on 3/20/13. There is no documentation in the MR that Pt #2 was given a list of other SNFs to chose from, informed of the freedom of choice and disclosure of the financial interest or affiliation Tivoli has with DSH. This is confirmed in interview with SWS E on 4/23/13 at 1:40 PM.

Pt #4's MR review on 4/23/13 at 10:25 AM revealed Pt #4 was admitted on [DATE] for hip surgery. The DC note by Con F on 12/24/12 state "A referral has been made to Tivoli", at 9:10 AM Con F documented "Patient's 2nd choice is CHCC...they do have female beds available. Anticipate dc Wed/Thursday." There is no documentation in the MR that Pt #4 was given a list of other SNFs to chose from, informed of the freedom of choice and disclosure of the financial interest or affiliation Tivoli has with DSH. This is confirmed in interview with SWS E on 4/23/13 at 1:40 PM.

Pt #5's MR review on 4/23/13 at 10:15 AM revealed Pt #5 was admitted for hip surgery. On 4/18/13 at 2:32 PM SW I documented "(Pt #5) has asked that we make a referral to Tivoli..." Per interview with Pt #5 on 4/23/12 at 9:25 AM no list of area SNFs was provided for review. Pt #5 stated "the doctor said we have a nice rehab place here." There is no documentation in the MR that Pt #4 was given a list of other SNFs to chose from, informed of the freedom of choice and disclosure of the financial interest or affiliation Tivoli has with DSH. This is confirmed in interview with DPI J on 4/23/13 at 10:15 AM.

Pt #7's MR review on 4/23/13 at 9:55 AM revealed Pt #7 was admitted for hip surgery. On 4/22/13 Con F documented at 8:38 AM "Referrals made to MCC and Tivoli per (SW G)." Per interview with Pt #7 on 4/23/13 at 9:40 AM, Pt #7 did not recall getting a list. There is no documentation in the MR that Pt #4 was given a list of other SNFs to chose from, informed of the freedom of choice and disclosure of the financial interest or affiliation Tivoli has with DSH. This is confirmed in interview with DPI J on 4/23/13 at 9:55 AM.

Pt #9's MR review on 4/23/13 at 2:00 PM revealed Pt #9 was admitted for hip surgery, and transferred to SB on 4/7/13, due to not wanting to go to a SNF. Con F documented on 4/12/13 "I reviewed the swing bed agreement with (Pt #9) and obtained signature. (Pt #9) is agreeable to HomeCare and would like me to make a referral to Divine Savior HomeCare" (affiliated with the hospital). There is no documentation in the MR that Pt #4 was given a list of other SNFs to chose from, informed of the freedom of choice and disclosure of the financial interest or affiliation Tivoli has with DSH. This is confirmed per telephone interview with DPI J on 4/24/13 at 11:50 AM.
VIOLATION: OUTPATIENT POST-ANESTHESIA EVALUATION Tag No: A1005
Based on MR review and interview with staff, in 3 of 4 surgical MRs reviewed (#1, 5 and 9) the facility failed to ensure the post anesthesia documentation is complete including vital signs, oxygen saturation, pain, nausea and vomiting, and hydration. This deficiency potentially affects all 32 In-Pts and Out-Pts seen in the facility on 4/23/13.

Findings include:

Pt #1's MR review on 4/23/13 at 10:55 AM revealed Pt #1 had surgical repair of the right hip on 3/11/13 under general anesthesia. The post anesthesia note completed on 3/11/13 at 3:00 PM have check marks next to "vital signs stable" and "no adverse anesthesia related complications noted, satisfactory progress and recovery". This does not constitute a compete post anesthesia note that includes documentation of vital signs, oxygen saturation, pain, nausea and vomiting, and hydration. This is confirmed in interview with DPI J on 4/23/13 at approximately 3:30 PM.

Pt #5's MR review on 4/23/13 at 10:15 AM revealed Pt #5 had surgical repair to the left hip on 4/19/13 under general anesthesia. The post anesthesia note completed on 4/19/13 at 2:00 PM has no documentation of Pt #5's post anesthesia status. This note does not constitute a compete post anesthesia note that includes documentation of vital signs, oxygen saturation, pain, nausea and vomiting, and hydration. This is confirmed in interview with DPI J on 4/23/13 at approximately 10:15 AM.

Pt #9's MR review on 4/23/13 at 2:00 PM revealed Pt #9 had surgical repair to the right hip on 4/7/13. The post anesthesia note completed on 4/7/13 at 12:15 PM have check marks next to "vital signs stable" and "no adverse anesthesia related complications noted, satisfactory progress and recovery". This note does not constitute a compete post anesthesia note that includes documentation of vital signs, oxygen saturation, pain, nausea and vomiting, and hydration. This is confirmed in interview with DPI J on 4/23/13 at approximately 3:30 PM.